Healthcare Provider Details

I. General information

NPI: 1720585029
Provider Name (Legal Business Name): ANDREA NICOLE HAYNES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/16/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 W LAKE ST
CHICAGO IL
60644-2342
US

IV. Provider business mailing address

108 S WALLER AVE
CHICAGO IL
60644
US

V. Phone/Fax

Practice location:
  • Phone: 773-378-3347
  • Fax:
Mailing address:
  • Phone: 601-405-4674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036156114
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: